Double Plus.indd - CAMAF

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS SUBJECT
TO PRE-AUTHORISATION
ATTENDING DOCTORS AND SPECIALISTS
CONSULTATIONS
MEDICAL AND SURGICAL PROCEDURES
INCLUDING CONFINEMENTS
AUXILIARY HEALTHCARE IN HOSPITAL
(EG. PHYSIOTHERAPY AND PSYCHOTHERAPY)
BLOOD TRANSFUSIONS
(IN AND OUT OF HOSPITAL)
RADIOLOGY IN HOSPITAL
ADVANCED SCANS
SUBJECT TO PRE-AUTHORISATION
PATHOLOGY IN HOSPITAL
INTERNAL PROSTHESIS
SUBJECT TO PRE-AUTHORISATION
HOME NURSING
UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION
STEP DOWN APPROVED FACILITIES
ONLY, UP TO 90 DAYS
SUBJECT TO PRE-AUTHORISATION
MEDICATION IN HOSPITAL
TTD MEDICATION UP TO ONE WEEK’S SUPPLY
INFERTILITY TREATMENT
SUBSTANCE ABUSE
CHRONIC PMB CDL MEDICATION AND
TREATMENT - SUBJECT TO
PRE-AUTHORISATION AND PROTOCOLS
REFER TO CHRONIC DISEASE LIST
PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT
TO REGISTRATION OF CONDITION AND
PRE-AUTHORISATION
CAMAF LIFESTYLE PROGRAMME
PER ADULT BENEFICIARY
DOUBLE PLUS
All benefi ts listed below are annual, unless otherwise stated. Where a condition qualifi es as a PMB and is
registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the
Medical Schemes Act.
IN HOSPITAL PRESCRIBED MINIMUM BENEFITS
100% of Negotiated Rate in general ward and specialised units
Up to 300% CBT
100% of Scheme Rate
100% CBT
100% of cost
100% CBT
100% CBT
100% Negotiated Rate
100% of cost
100% CBT
100% Negotiated Rate
100% SEP plus dispensing fee
100% SEP plus dispensing fee
Treatment limited to R 37 800 per family
PMB applied to hospital based treatment and limited to one rehabilitation treatment per benefi ciary per year,
subject to pre-authorisation and limited to 21 days
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
PREVENTATIVE WELLNESS COVER
INCLUDES: An initial assessment by a nurse within Clicks or Dischem clinics or at a Biokineticist within the network
• A personalised exercise and eating programme • Reporting and goal setting • Follow-up measuring and tracking
at Clicks, Pick ‘n Pay or Dischem clinics, Lifezone or Healthzones • Access to the Web Life Zone • Regular ongoing
communication • Telephonic access to a coach, Biokineticist or Dietician.
ONE GP CONSULTATION ONLY
100% CBT per benefi ciary
ICD 10 CODE SPECIFIC TO GENERAL
CHECK UP ONLY
ONE SPECIALIST CONSULTATION
100% CBT per benefi ciary
* ICD 10 CODE SPECIFIC TO GENERAL CHECK
UP ONLY. GYNAECOLOGISTS, UROLOGISTS, OR
SPECIALIST PHYSICIANS FOR BENEFICIARIES
OVER 16 YEARS. PAEDIATRICIAN FOR
BENEFICIARIES UNDER 16 YEARS.
PSYCHOTHERAPY
100% CBT limited to R 7 550 per benefi ciary
SUBJECT TO REGISTRATION ON
EMOTIONAL WELLNESS PROGRAMME
ONE DENTISTRY CONSULTATION
100% CBT per benefi ciary
GENERAL CHECK UP ONLY
ECG (GP AND SPECIALIST PHYSICIANS)
100% CBT per adult benefi ciary
* ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY
* Refer to website for relevant ICD 10 codes
ONE CONSULTATION AT AN OPTOMETRIST 100% Optical Assistant fees
METABOLIC SCREENING FOR NEW BORN BABIES 100% Negotiated Rate per new born baby
IMMUNISATION (COST OF IMMUNISATION ONLY) SEP plus a dispensing fee, limited to Adults R 1 620 - Child R 2 700
CERVICAL CANCER VACCINE
Females between 9 and 16 years of age
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BASIC AND ADVANCED RADIOLOGY
OUT OF HOSPITAL
Must be performed by a registered radiologist,
on referral from medical practitioner only.
Advanced scans subject to pre-authorisation
PATHOLOGY OUT OF HOSPITAL
Performed by a registered pathologist and
referred by a medical practitioner
POST-HOSPITALISATION UP TO 90 DAYS
MEDICATION FOR ADDITIONAL CHRONIC
CONDITIONS
(SUBJECT TO PRE-AUTHORISATION) REFER TO
ADDITIONAL CHRONIC CONDITIONS LIST
EXTERNAL APPLIANCES
IN AND OUT OF HOSPITAL
PURCHASE, HIRE AND MAINTENANCE
HEARING AIDS - 1 CLAIM PER 3 YEAR
CYCLE FOR OVER 16 YEARS OF AGE
YOUNGER THAN 16 YEARS OF AGE
- 18 MONTH CYCLE
WHEELCHAIRS - 3 YEAR CYCLE
INSULIN PUMPS, SUBJECT TO
PRE-AUTHORISATION - 4 YEAR CYCLE
NETCARE 911
EMERGENCY SERVICES
DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT
GP’S, SPECIALISTS AND DENTISTS
CONSULTATIONS, PROCEDURES AND
RADIOLOGY PERFORMED BY THESE
PRACTITIONERS; BASIC DENTISTRY
ACUTE MEDICATION
INCLUDING INJECTIONS AND MATERIALS
NON-DSP VISITS TO DOCTORS’ ROOMS
CASUALTY AND OUT PATIENT
TREATMENT AT A HOSPITAL
ALL MEDICATIONS WILL BE PAID OUT OF
ACUTE MEDICATION BENEFIT
HOME NURSING
AUXILIARY HEALTH
AUDIOLOGY, CHIROPRACTORS, OPTICIANS,
HOMEOPATHS, OCCUPATIONAL THERAPY,
PHYSIOTHERAPISTS, PODIATRY AND SPEECH
THERAPY
ADVANCED DENTISTRY
CROWNS, BRIDGES AND DENTURES
ANTE-NATAL CLASSES SUBJECT TO
ENROLMENT ON THE MOTHER-TO-BE PROGRAMME
SPECTACLES AND LENSES
FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE
STATED
100% CBT
100% Negotiated Rate
300% CBT for attending practitioners
100% CBT for auxiliary services
100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT
Unlimited
Subject to Netcare 911 authorisation
OTHER BENEFITS
(per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT
Annual Overall Limits
Adult R 8 000
Child
80% CBT
R 5 590
80% SEP plus a dispensing fee
Not applicable
80% CBT
80% CBT up to 21 days
80% CBT
80% CBT limited to:
Mo R 8 000
M1 R 11 660
M2+ R 15 660
Subject to Annual Benefi ts
DOUBLE PLUS
OTHER BENEFITS
(per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT
100% of cost subject to the overall limit of R43 200 per benefi ciary and subject to the following sub-limits:
Hearing Aids: R 43 200
Wheelchairs for Quadriplegics: R 43 200
Standard Wheelchairs: R 27 550
Insulin Pumps: R 28 080
Other external appliances: R 9 180
• Baby Apnoea monitors: R 1 600
• Breast pumps: R 2 700
OTC MEDICATION
80% SEP plus a dispensing fee, limited to R 1 190 per benefi ciary
LASER K
80% CBT limited to R 3 000 per eye
NO APPROVAL FOR SURGERY WHERE SPECTACLES
OBTAINED IN PREVIOUS 12 MONTHS
ANTE-NATAL FOETAL SCANS PER PREGNANCY 3 Scans at 80% CBT
80% CBT limited to R 1 190 per pregnancy
Consultion: See Preventative Wellness
Add ons R 700
Single Vision R 700 OR
Bifocal R 1 900 OR
Varifocal R 2 920 AND
Frames R 1 950 OR
Contact lenses R 2 700
Lenses, frames etc 80% Optical Assistant Fees
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MONTHLY RISK CONTRIBUTION Adult R 2 040
Child R 1 240
MONTHLY MSA CONTRIBUTION
Adult R 260
Child R 173
TOTAL MONTHLY CONTRIBUTION
Adult R 2 300
Child R 1 413
DOUBLE PLUS
MONTHLY CONTRIBUTION RATES
GLOSSARY
* More details available on the website www.camaf.co.za - for full explanations, consult the Registered Rules
ADULT
CBT
CDL
CML/ Formulary
CHILD
DISPENSING FEES
DSP
DTP
ICD 10 CODE
METABOLIC SCREENING Newborn screening whereby rare disorders are detected by a blood test done 48-72 hours after birth.
MMAP
Maximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse
for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.
MSA
NEGOTIATED RATE
PMB
PRE-AUTHORISATION
PROTOCOL
RISK CONTRIBUTIONS
RP
SALARY
SCHEME RATE
SEP
TTO
Refers to the member and dependants who are 22 or older at any time in the year of cover.
CAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates,
increased annually by CPI. Tariff diff ers per type of service provider and % paid on diff erent options.
Chronic Disease List - the list of PMB’s includes 27 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis,
treatment and care of these conditions. Members must register their conditions to qualify for benefi ts. Schemes can provide protocols in terms of
the range (RP and Formularies) and delivery of medication (DSP’s).
Condition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate
for the condition, that do not require authorisation. This is maintained by the Scheme and diff ers per Option. Reference pricing may still apply.
Refers to a dependant who is younger than an adult, as defi ned above.
Fee negotiated by the Scheme with Network pharmacies and added to SEP.
The network of service providers contracted to provide healthcare services to members, eg. Diabetes programme (CDE), HIV programme
(LifeSense) PPN for optical benefi ts on First Choice and Network Choice, Pharmacy networks for all chronic medications and Netcare hospital group
for Network Choice hospital admissions.
The regulations to the Medical Schemes Act in Annexure A provide a list of conditions identifi ed as Prescribed Minimum Benefi ts. The List is in
the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specifi c diagnosis to a treatment/procedure and therefore broadly indicates how
each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of
diagnosis, treatment and care of these conditions.
Stands for International Classifi cation of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World
Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. Jo3.9 is a ICD-10
code for acute tonsillitis (unspecifi ed) and G40.9 denotes epilepsy (unspecifi ed). These codes are used to inform medical schemes about what
conditions their members were treated for so that claims can be paid from the correct benefi t.
Medical Savings Account - accrued monthly but the annualised amount of savings is available immediately and can be used for :
• top up on cost of service charged by a doctor
• extension when an overall benefi t has been exceeded
• exclusion from benefi ts
This is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
Prescribed Minimum Benefi ts - as set down in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the
diagnosis, treatment and care of:
• Any emergency medical condition
• A limited set of 270 medical conditions (Defi ned in DTP’s)
• 27 chronic conditions defi ned in the CDL
• These costs may not be paid from member’s savings benefi t and cost saving measures can be used by way of utilising DSP’s, Reference
Pricing and Formularies.
A member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly
disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to
Pre-authorisation but members should notify the Scheme as soon as possible after the event.
Means a set of guidelines in relation to diagnostic testing and treatments for specifi c conditions and includes, but is not limited to, clinical
practice guidelines, standard treatment guidelines and disease management guidelines.
Those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the MSA.
Reference pricing is the maximum price for which the Scheme will be liable for specifi c medicine or classes of medicine, listed on the
Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated
that a co-payment will apply. This includes MMAP.
Total cost to company prior to deductions.
The maximum rate paid by the scheme to providers of healthcare services, based on SAMA (Private) rates, increased annually by CPI. Tariff
diff ers per type of service provider and % paid on diff erent options.
Single Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers.
“To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.
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